The Culdotomy FourS Two U procedure for transvaginal access to the peritoneal cavity

Vaginal ultrasound-guided Pouch of Douglas robotic entry in a live ovine model and human female cadaveric specimens

We aimed to determine whether intraoperative ultrasound is a feasible tool for visualization of the pouch of Douglas (POD) to facilitate a safe vaginal entry for direct robotic vaginal trocar insertion for pelvic floor surgery. Endovaginal ultrasound-guided needle insertion of a trocar into the POD was performed in six fresh frozen female cadavers and a live sheep animal model. Using an endovaginal probe the POD was identified as a fluid-filled space clear of bowel or adhesions, then a Veress needle was also used to confirm POD localization. Access to the POD was achieved using a robotic trocar designed for this purpose. The animal study was approved by the Ethics Committee of Asaf-Harofe hospital. Direct visualization during laparoscopy in cadavers and open cadaveric dissections confirmed safe POD entry and accurate trocar placement. This method was found feasible in the development of a safe vaginal entry in both the animal and cadaveric model, possibly negating the need for laparoscopic umbilical observation.

Evaluation of transvaginal peritoneal surgery in young female patients

BACKGROUND

The transvaginal approach is being used for natural orifice transluminal endoscopic surgery (NOTES), and reports of the clinical use of transvaginal NOTES have increased rapidly. However, hasty use of a transvaginal route may cause unexpected complications. Infertility or dyspareunia after transvaginal NOTES in young women is one of the most important issues to be resolved. The purpose of this study was to assess long-term complications, including infertility and dyspareunia, after transvaginal peritoneal surgery.

METHODS

An anonymous questionnaire was sent to 73 young patients who had undergone ovarian cystectomy using a transvaginal approach from 2003 to 2011. The questionnaire contained 15 questions; 6 dealt with fertility, and 8 dealt with discomfort after surgery. A 5-point scale was used to evaluate patients' overall satisfaction with surgery.

RESULTS

Forty-four (60 %) questionnaires were returned. The patients' mean age was 33.0 years, and the mean postoperative follow-up period was 16.5 months. Of responders younger than age 40 years, 24 did not use contraception, and 9 (38 %) conceived. The pregnancy rate among women younger than age 30 years was 60 %. Two (5 %) women reported temporary dyspareunia 1 month after surgery, but none developed permanent dyspareunia. The average patient satisfaction score was 4.12.

CONCLUSIONS

There was no evidence to suggest that transvaginal peritoneal surgery causes infertility or dyspareunia. The majority of patients gave a high evaluation to vaginal ovarian cystectomy, suggesting the usability of a transvaginal approach for intraperitoneal surgery in young premenopausal women.

An alternative system for transvaginal removal of dermoid cyst and a comparative study with laparoscopy

The objective was to introduce a new system for transvaginal removal of ovarian cyst and to evaluate its feasibility. With a new transvaginal system, ultrasound-assisted culdotomy, and laparoscopy supported cystectomy if vaginal procedure failed. The authors conducted a retrospective review in which 35 cases using new vaginal ovarian cystectomy were compared with 40 cases of laparoscopic cystectomy for the treatment of dermoid cyst. All cystectomies were completed without conversion to laparotomy and complications. In a case from vaginal group, laparoscopy was required. No differences existed in operating time, hemoglobin decrease, and C-reactive protein value between groups. Laparoscopically supported vaginal ovarian cystectomy with ultrasound-guided culdotomy was equivalent to laparoscopic cystectomy as to invasiveness and preserved the option of a completely vaginal approach. When a presumed benign dermoid cyst is located in cul-de-sac, this operation may represent a preferable alternative to an exclusively laparoscopic or exclusively vaginal ovarian cystectomy.

[The transvaginal approach in acute appendicitis]

INTRODUCTION

The purpose of this work is to present 8 minilaparoscopic-assisted transvaginal appendectomies using rigid instruments in patients with acute appendicitis.

MATERIAL AND METHODS

Eight minilaparoscopic-assisted transvaginal appendectomies were performed from the 10th of August 2009 to the 30th of June 2010. The inclusion criteria were women between 18 and 65 years of age with a diagnosis of acute appendicitis. The exclusion criteria were palpable masses, appendicular abscesses, ASA III and IV; morbid obesity (BMI > 35); gynaecological infections; virgin patients and pregnant women. The surgical intervention was performed with rigid instruments. Surgical time, the need for post-operative analgesics, and post-surgical complications.

RESULTS

The age range varied between 18 and 42 years, with a mean of 29.6 years. The mean surgical time was 48.3 minutes (37-75). Analgesics were given to 2 patients after surgery (1 parenteral and 1 oral). Five patients were discharged before 24 hours and 3 at 48 hours. There were no post-operative complications.

CONCLUSIONS

Minilaparoscopic-assisted transvaginal appendectomy with rigid instruments, in selected women is a feasible and safe method, and with better aesthetic results than laparoscopic appendectomy, but future studies will be required that can demonstrate its advantages.

The culdotomy two U procedure for vaginal ovarian cystectomy

When transvaginal removal of ovarian cysts is performed successfully, the procedure compares favorably with laparoscopy in terms of invasiveness. However, the approach into peritoneal cavity has been laborious. The objective was to evaluate feasibility of an ultrasound-guided culdotomy using a newly developed umbrella needle. New culdotomy was performed on 36 patients with ovarian cysts. Each cyst was directly punctured by the needle from vagina under ultrasound guidance. The vaginal walls on both sides of the needle were incised with an electric scalpel. Through the wound, cyst was exteriorized and enucleated. Preoperative characteristics of patients, outcome, operating time, blood loss, complications, and cyst histology were analyzed. Culdotomy was performed successfully in all cases. Operating time was less than 10 minutes and blood loss was less than 10 mL. There were no culdotomy-associated complications. Culdotomy assisted by ultrasound imaging and an umbrella needle is a simple, safe, and reliable method for vaginal ovarian cystectomy.